Abstract
Cardiovascular disease remains a leading cause of death worldwide despite important advances in modern medical and surgical therapies. As human adult cardiomyocytes have limited regenerative ability, cardiomyocytes lost after myocardial infarction are replaced by fibrotic scar tissue, leading to cardiac dysfunction and heart failure. To replace lost cardiomyocytes, a promising approach is direct cardiac reprogramming, in which cardiac fibroblasts are transdifferentiated into induced cardiomyocyte-like cells (iCMs). Here we review cardiac reprogramming cocktails (including transcription factors, microRNAs and small molecules) that mediate iCM generation. We also highlight mechanistic studies exploring the barriers to and facilitators of this process. We then review recent progress in iCM reprogramming, with a focus on single-cell '-omics' research. Finally, we discuss obstacles to clinical application.
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 digital issues and online access to articles
$119.00 per year
only $9.92 per issue
Buy this article
- Purchase on SpringerLink
- Instant access to full article PDF
Prices may be subject to local taxes which are calculated during checkout
Similar content being viewed by others
References
Murry, C. E., Reinecke, H. & Pabon, L. M. Regeneration gaps: observations on stem cells and cardiac repair. J. Am. Coll. Cardiol. 47, 1777–1785 (2006).
Yusuf, S. et al. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N. Engl. J. Med. https://doi.org/10.1056/nejm199108013250501 (1991).
Prabhu, S. D. & Frangogiannis, N. G. The biological basis for cardiac repair after myocardial infarction: from inflammation to fibrosis. Circ. Res. 119, 91–112 (2016).
Takahashi, K. & Yamanaka, S. Induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors. Cell https://doi.org/10.1016/j.cell.2006.07.024 (2006). This study demonstrated reversion of fibroblasts to pluripotency following overexpression of four TFs.
Ieda, M. et al. Direct reprogramming of fibroblasts into functional cardiomyocytes by defined factors. Cell https://doi.org/10.1016/j.cell.2010.07.002 (2010). This study identified reprogramming factors that could reprogram CFs into iCMs in vitro.
Davis, R. L., Weintraub, H. & Lassar, A. B. Expression of a single transfected cDNA converts fibroblasts to myoblasts. Cell https://doi.org/10.1016/0092-8674(87)90585-X (1987). This study demonstrated that overexpression of one TF, MYOD, could change cell fate.
Zhou, Y. et al. Bmi1 is a key epigenetic barrier to direct cardiac reprogramming. Cell Stem Cell https://doi.org/10.1016/j.stem.2016.02.003 (2016).
Wang, L. et al. Down-regulation of Beclin1 promotes direct cardiac reprogramming. Sci. Transl. Med. https://doi.org/10.1126/scitranslmed.aay7856 (2020).
Huang, P. et al. Induction of functional hepatocyte-like cells from mouse fibroblasts by defined factors. Nature https://doi.org/10.1038/nature10116 (2011).
Vierbuchen, T. et al. Direct conversion of fibroblasts to functional neurons by defined factors. Nature https://doi.org/10.1038/nature08797 (2010).
Scesa, G., Adami, R. & Bottai, D. iPSC preparation and epigenetic memory: does the tissue origin matter? Cells 10, 1470 (2021).
Furtado, M. B. et al. Cardiogenic genes expressed in cardiac fibroblasts contribute to heart development and repair. Circ. Res. 114, 1422–1434 (2014).
Protze, S. et al. A new approach to transcription factor screening for reprogramming of fibroblasts to cardiomyocyte-like cells. J. Mol. Cell. Cardiol. https://doi.org/10.1016/j.yjmcc.2012.04.010 (2012).
Sadahiro, T., Yamanaka, S. & Ieda, M. Direct cardiac reprogramming: progress and challenges in basic biology and clinical applications. Circ. Res. 116, 1378–1391 (2015).
Vidal, R. et al. Transcriptional heterogeneity of fibroblasts is a hallmark of the aging heart. JCI Insight 4, e131092 (2019).
Trial, J. & Cieslik, K. A. Changes in cardiac resident fibroblast physiology and phenotype in aging. Am. J. Physiol. Heart Circ. Physiol. 315, H745–H755 (2018).
Wang, L. et al. Stoichiometry of Gata4, Mef2c, and Tbx5 influences the efficiency and quality of induced cardiac myocyte reprogramming. Circ. Res. https://doi.org/10.1161/CIRCRESAHA.116.305547 (2015). This study optimized the stoichiometry of GMT protein expression, resulting in efficient iCM reprogramming.
Song, K. et al. Heart repair by reprogramming non-myocytes with cardiac transcription factors. Nature https://doi.org/10.1038/nature11139 (2012). This study demonstrated that GHMT can convert resident CFs into iCMs after MI in mice.
Addis, R. C. et al. Optimization of direct fibroblast reprogramming to cardiomyocytes using calcium activity as a functional measure of success. J. Mol. Cell. Cardiol. https://doi.org/10.1016/j.yjmcc.2013.04.004 (2013).
Christoforou, N. et al. Transcription factors MYOCD, SRF, Mesp1 and SMARCD3 enhance the cardio-inducing effect of GATA4, TBX5, and MEF2C during direct cellular reprogramming. PLoS ONE https://doi.org/10.1371/journal.pone.0063577 (2013).
Zhou, H. et al. ZNF281 enhances cardiac reprogramming by modulating cardiac and inflammatory gene expression. Genes Dev. https://doi.org/10.1101/gad.305482.117 (2017).
Garry, G. A. et al. The histone reader PHF7 cooperates with the SWI/SNF complex at cardiac super enhancers to promote direct reprogramming. Nat. Cell Biol. https://doi.org/10.1038/s41556-021-00668-z (2021).
Wang, H. et al. Cross-lineage potential of Ascl1 uncovered by comparing diverse reprogramming regulatomes. Cell Stem Cell 29, 1491–1504 (2022). This study found that ASCL1, a neuron-specific TF, could drive efficient cardiac reprogramming together with MEF2C.
Tsao, C. W. et al. Heart disease and stroke statistics—2022 update: a report from the American Heart Association. Circulation 145, e153–e639 (2022).
Xie, Y. et al. MircroRNA-10b promotes human embryonic stem cell-derived cardiomyocyte proliferation via novel target gene LATS1. Mol. Ther. Nucleic Acids https://doi.org/10.1016/j.omtn.2019.11.026 (2020).
Oikonomopoulos, A., Kitani, T. & Wu, J. C. Pluripotent stem cell-derived cardiomyocytes as a platform for cell therapy applications: progress and hurdles for clinical translation. Mol. Ther. 26, 1624–1634 (2018).
Qian, L. et al. In vivo reprogramming of murine cardiac fibroblasts into induced cardiomyocytes. Nature https://doi.org/10.1038/nature11044 (2012). This study demonstrated the ability of in vivo cardiac reprogramming to repair the heart.
Tani, H. et al. Direct reprogramming improves cardiac function and reverses fibrosis in chronic myocardial infarction. Circulation 147, 223–238 (2023). This study demonstrated that cardiac reprogramming could repair chronic MI with established scars.
Jayawardena, T. M. et al. MicroRNA-mediated in vitro and in vivo direct reprogramming of cardiac fibroblasts to cardiomyocytes. Circ. Res. https://doi.org/10.1161/CIRCRESAHA.112.269035 (2012). This study demonstrated that miRNAs have the ability to convert fibroblasts into iCMs both in vitro and in vivo.
Fu, Y. et al. Direct reprogramming of mouse fibroblasts into cardiomyocytes with chemical cocktails. Cell Res. https://doi.org/10.1038/cr.2015.99 (2015).
Cao, N. et al. Conversion of human fibroblasts into functional cardiomyocytes by small molecules. Science https://doi.org/10.1126/science.aaf1502 (2016).
Huang, C., Tu, W., Fu, Y., Wang, J. & Xie, X. Chemical-induced cardiac reprogramming in vivo. Cell Res. https://doi.org/10.1038/s41422-018-0036-4 (2018).
Kim, H. et al. Ultraefficient extracellular vesicle-guided direct reprogramming of fibroblasts into functional cardiomyocytes. Sci. Adv. 8, eabj6621 (2022).
Miyamoto, K. et al. Direct in vivo reprogramming with Sendai virus vectors improves cardiac function after myocardial infarction. Cell Stem Cell https://doi.org/10.1016/j.stem.2017.11.010 (2018).
Chang, Y. et al. Efficient in vivo direct conversion of fibroblasts into cardiomyocytes using a nanoparticle-based gene carrier. Biomaterials 192, 500–509 (2019).
Shiba, Y. et al. Allogeneic transplantation of iPS cell-derived cardiomyocytes regenerates primate hearts. Nature 538, 388–391 (2016).
Fu, J. D. et al. Direct reprogramming of human fibroblasts toward a cardiomyocyte-like state. Stem Cell Reports https://doi.org/10.1016/j.stemcr.2013.07.005 (2013).
Wada, R. et al. Induction of human cardiomyocyte-like cells from fibroblasts by defined factors. Proc. Natl Acad. Sci. USA https://doi.org/10.1073/pnas.1304053110 (2013).
Nam, Y. J. et al. Reprogramming of human fibroblasts toward a cardiac fate. Proc. Natl Acad. Sci. USA https://doi.org/10.1073/pnas.1301019110 (2013).
Singh, V. P. et al. MiR-590 promotes transdifferentiation of porcine and human fibroblasts toward a cardiomyocyte-like fate by directly repressing specificity protein 1. J. Am. Heart Assoc. https://doi.org/10.1161/JAHA.116.003922 (2016).
Christoforou, N. et al. Core transcription factors, microRNAs, and small molecules drive transdifferentiation of human fibroblasts towards the cardiac cell lineage. Sci. Rep. https://doi.org/10.1038/srep40285 (2017).
Singh, V. P. et al. Hippo pathway effector Tead1 induces cardiac fibroblast to cardiomyocyte reprogramming. J. Am. Heart Assoc. 10, e022659 (2021).
Zhou, Y. et al. Single-cell transcriptomic analyses of cell fate transitions during human cardiac reprogramming. Cell Stem Cell https://doi.org/10.1016/j.stem.2019.05.020 (2019). This study revealed an early decision point at which a cell decides to either progress toward the CM fate or regress to its initial fibroblast state during human iCM reprogramming.
Nam, Y. J. et al. Induction of diverse cardiac cell types by reprogramming fibroblasts with cardiac transcription factors. Development 141, 4267–4278 (2014).
Zhang, Z., Villalpando, J., Zhang, W. & Nam, Y. J. Chamber-specific protein expression during direct cardiac reprogramming. Cells 10, 1513 (2021).
Van Handel, B., Wang, L. & Ardehali, R. Environmental factors influence somatic cell reprogramming to cardiomyocyte-like cells. Semin. Cell Dev. Biol. 122, 44–49 (2022).
Ifkovits, J. L., Addis, R. C., Epstein, J. A. & Gearhart, J. D. Inhibition of TGFβ signaling increases direct conversion of fibroblasts to induced cardiomyocytes. PLoS ONE https://doi.org/10.1371/journal.pone.0089678 (2014).
Zhao, Y. et al. High-efficiency reprogramming of fibroblasts into cardiomyocytes requires suppression of pro-fibrotic signalling. Nat. Commun. https://doi.org/10.1038/ncomms9243 (2015).
Mohamed, T. M. A. et al. Chemical enhancement of in vitro and in vivo direct cardiac reprogramming. Circulation https://doi.org/10.1161/CIRCULATIONAHA.116.024692 (2017).
Muraoka, N. et al. MiR‐133 promotes cardiac reprogramming by directly repressing Snai1 and silencing fibroblast signatures. EMBO J. https://doi.org/10.15252/embj.201387605 (2014).
Kurotsu, S. et al. Soft matrix promotes cardiac reprogramming via inhibition of YAP/TAZ and suppression of fibroblast signatures. Stem Cell Reports 15, 612–628 (2020).
Zhou, H., Dickson, M. E., Kim, M. S., Bassel-Duby, R. & Olson, E. N. Akt1/protein kinase B enhances transcriptional reprogramming of fibroblasts to functional cardiomyocytes. Proc. Natl Acad. Sci. USA https://doi.org/10.1073/pnas.1516237112 (2015).
Abad, M. et al. Notch inhibition enhances cardiac reprogramming by increasing MEF2C transcriptional activity. Stem Cell Reports https://doi.org/10.1016/j.stemcr.2017.01.025 (2017).
Hashimoto, H. et al. Cardiac reprogramming factors synergistically activate genome-wide cardiogenic stage-specific enhancers. Cell Stem Cell https://doi.org/10.1016/j.stem.2019.03.022 (2019).
Muraoka, N. et al. Role of cyclooxygenase-2-mediated prostaglandin E2–prostaglandin E receptor 4 signaling in cardiac reprogramming. Nat. Commun. 10, 674 (2019).
Yamakawa, H. et al. Fibroblast growth factors and vascular endothelial growth factor promote cardiac reprogramming under defined conditions. Stem Cell Reports https://doi.org/10.1016/j.stemcr.2015.10.019 (2015).
Mathison, M. et al. In vivo cardiac cellular reprogramming efficacy is enhanced by angiogenic preconditioning of the infarcted myocardium with vascular endothelial growth factor. J. Am. Heart Assoc. 1, e005652 (2012).
Liu, Z. et al. Re-patterning of H3K27me3, H3K4me3 and DNA methylation during fibroblast conversion into induced cardiomyocytes. Stem Cell Res. https://doi.org/10.1016/j.scr.2016.02.037 (2016).
Dal-Pra, S., Hodgkinson, C. P., Mirotsou, M., Kirste, I. & Dzau, V. J. Demethylation of H3K27 is essential for the induction of direct cardiac reprogramming by miR combo. Circ. Res. https://doi.org/10.1161/CIRCRESAHA.116.308741 (2017).
Singhal, N. et al. Chromatin-remodeling components of the BAF complex facilitate reprogramming. Cell 141, 943–955 (2010).
Sevinç, K. et al. BRD9-containing non-canonical BAF complex maintains somatic cell transcriptome and acts as a barrier to human reprogramming. Stem Cell Reports 17, 2629–2642 (2022).
Takeuchi, J. K. & Bruneau, B. G. Directed transdifferentiation of mouse mesoderm to heart tissue by defined factors. Nature 459, 708–711 (2009).
Testa, G. et al. Bmi1 inhibitor PTC-209 promotes chemically-induced direct cardiac reprogramming of cardiac fibroblasts into cardiomyocytes. Sci. Rep. 10, 7129 (2020).
Liu, L. et al. Targeting Mll1 H3K4 methyltransferase activity to guide cardiac lineage specific reprogramming of fibroblasts. Cell Discov. https://doi.org/10.1038/celldisc.2016.36 (2016).
Zhou, Y. et al. A loss of function screen of epigenetic modifiers and splicing factors during early stage of cardiac reprogramming. Stem Cells Int. 2018, 3814747 (2018).
Kida, Y. S. et al. ERRs mediate a metabolic switch required for somatic cell reprogramming to pluripotency. Cell Stem Cell 16, 547–555 (2015).
Zheng, X. et al. Metabolic reprogramming during neuronal differentiation from aerobic glycolysis to neuronal oxidative phosphorylation. eLife 5, e13374 (2016).
Gascón, S. et al. Identification and successful negotiation of a metabolic checkpoint in direct neuronal reprogramming. Cell Stem Cell 18, 396–409 (2016).
Lopaschuk, G. D. & Jaswal, J. S. Energy metabolic phenotype of the cardiomyocyte during development, differentiation, and postnatal maturation. J. Cardiovasc. Pharmacol. 56, 130–140 (2010).
Zhou, Y. et al. Comparative gene expression analyses reveal distinct molecular signatures between differentially reprogrammed cardiomyocytes. Cell Rep. 20, 3014–3024 (2017).
Wang, Y., Shi, S., Liu, H. & Meng, L. Hypoxia enhances direct reprogramming of mouse fibroblasts to cardiomyocyte-like cells. Cell. Reprogram. https://doi.org/10.1089/cell.2015.0051 (2016).
Murray, T. V. A., Ahmad, A. & Brewer, A. C. Reactive oxygen at the heart of metabolism. Trends. Cardiovasc. Med. 24, 113–120 (2014).
Talkhabi, M., Pahlavan, S., Aghdami, N. & Baharvand, H. Ascorbic acid promotes the direct conversion of mouse fibroblasts into beating cardiomyocytes. Biochem. Biophys. Res. Commun. 463, 699–705 (2015).
Wang, X. et al. Selenium augments microRNA directed reprogramming of fibroblasts to cardiomyocytes via Nanog. Sci. Rep. 6, 23017 (2016).
Paredes, A. et al. γ-Linolenic acid in maternal milk drives cardiac metabolic maturation. Nature 618, 365–373 (2023).
Stone, N. R. et al. Context-specific transcription factor functions regulate epigenomic and transcriptional dynamics during cardiac reprogramming. Cell Stem Cell https://doi.org/10.1016/j.stem.2019.06.012 (2019).
Sauls, K. et al. Initiating events in direct cardiomyocyte reprogramming. Cell Rep. https://doi.org/10.1016/j.celrep.2018.01.047 (2018).
Xie, Y., Liu, J. & Qian, L. Direct cardiac reprogramming comes of age: recent advance and remaining challenges. Semin. Cell Dev. Biol. https://doi.org/10.1016/j.semcdb.2021.07.010 (2022).
Ali, S. R. et al. Developmental heterogeneity of cardiac fibroblasts does not predict pathological proliferation and activation. Circ. Res. 115, 625–635 (2014).
Liu, Z. et al. Single-cell transcriptomics reconstructs fate conversion from fibroblast to cardiomyocyte. Nature https://doi.org/10.1038/nature24454 (2017). This study constructed the routes of mouse iCM generation using scRNA-seq and discovered the critical role of the splicing factor PTBP1 during mouse cardiac reprogramming.
Wang, L. et al. Single-cell dual-omics reveals the transcriptomic and epigenomic diversity of cardiac non-myocytes. Cardiovasc. Res. https://doi.org/10.1093/cvr/cvab134 (2021).
Trapnell, C. Defining cell types and states with single-cell genomics. Genome Res. https://doi.org/10.1101/gr.190595.115 (2015).
Buenrostro, J. D. et al. Single-cell chromatin accessibility reveals principles of regulatory variation. Nature https://doi.org/10.1038/nature14590 (2015).
VanInsberghe, M., van den Berg, J., Andersson-Rolf, A., Clevers, H. & van Oudenaarden, A. Single-cell Ribo-seq reveals cell cycle-dependent translational pausing. Nature https://doi.org/10.1038/s41586-021-03887-4 (2021).
Rotem, A. et al. Single-cell ChIP–seq reveals cell subpopulations defined by chromatin state. Nat. Biotechnol. https://doi.org/10.1038/nbt.3383 (2015).
Karemaker, I. D. & Vermeulen, M. Single-cell DNA methylation profiling: technologies and biological applications. Trends Biotechnol. https://doi.org/10.1016/j.tibtech.2018.04.002 (2018).
Stoeckius, M. et al. Simultaneous epitope and transcriptome measurement in single cells. Nat. Methods https://doi.org/10.1038/nmeth.4380 (2017).
Xie, Y. et al. Translational landscape of direct cardiac reprogramming reveals a role of Ybx1 in repressing cardiac fate acquisition. Nat. Cardiovasc. Res. 2, 1060–1077 (2023).
Rurik, J. G. et al. CAR T cells produced in vivo to treat cardiac injury. Science 375, 91–96 (2022).
Kaur, K. et al. Direct reprogramming induces vascular regeneration post muscle ischemic injury. Mol. Ther. 29, 3042–3058 (2021).
Barnabei, M. S., Palpant, N. J. & Metzger, J. M. Influence of genetic background on ex vivo and in vivo cardiac function in several commonly used inbred mouse strains. Physiol. Genomics 42A, 103–113 (2010).
Vaillant, F. et al. Mouse strain differences in metabolic fluxes and function of ex vivo working hearts. Am. J. Physiol. Heart Circ. Physiol. 306, H78–H87 (2014).
Park, S. et al. Genetic regulation of fibroblast activation and proliferation in cardiac fibrosis. Circulation 138, 1224–1235 (2018).
Acknowledgements
R.A. is supported by US National Institutes of Health (NIH) grants R01 NS112256, R01 HL148714 and R01 GM127985. Y.X. is supported by American Heart Association (AHA) grant 23POST1026377. L.Q. is supported by AHA grant 20EIA35310348 and NIH‒NHLBI grant R35HL155656.
Author information
Authors and Affiliations
Contributions
Y.X. wrote the draft and created figures. B.V.H., L.Q. and R.A. made key edits and additions.
Corresponding author
Ethics declarations
Competing interests
The authors declare no competing interests.
Peer review
Peer review information
Nature Cardiovascular Research thanks Gentaro Ikeda, Taketaro Sadahiro and Kunhua Song for their contribution to the peer review of this work.
Additional information
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Xie, Y., Van Handel, B., Qian, L. et al. Recent advances and future prospects in direct cardiac reprogramming. Nat Cardiovasc Res 2, 1148–1158 (2023). https://doi.org/10.1038/s44161-023-00377-w
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1038/s44161-023-00377-w
